ROYAL COLLEGE OF GENERAL PRACTITIONERS CURRICULUM STATEMENT 15.3
Drug and Alcohol Problems
One in a series of curriculum statements produced by
the Royal College of General Practitioners:
1. Being a General Practitioner
2. The General Practice Consultation
3. Personal and Professional Responsibilities
3.1
Clinical Governance
3.2
Patient Safety
3.3
Clinical Ethics and Values-Based Practice
3.4
Promoting Equality and Valuing Diversity
3.5
Evidence-Based Practice
3.6
Research and Academic Activity
3.7
Teaching, Mentoring and Clinical Supervision
4. Management
4.1
Management in Primary Care
4.2
Information Management and Technology
5. Healthy People: promoting health and preventing disease
6. Genetics in Primary Care
7. Care of Acutely Ill People
8. Care of Children and Young People
9. Care of Older Adults
10. Gender-Specific Health Issues
10.1 Women’s Health
10.2 Men’s Health
11. Sexual Health
12. Care of People with Cancer & Palliative Care
13. Care of People with Mental Health Problems
14. Care of People with Learning Disabilities
15. Clinical Management
15.1 Cardiovascular Problems
15.2 Digestive Problems
15.3 Drug and Alcohol Problems
15.4 ENT and Facial Problems
15.5 Eye Problems
15.6 Metabolic Problems
15.7 Neurological Problems
15.8 Respiratory Problems
15.9 Rheumatology and Conditions of the Musculoskeletal System
(including Trauma)
15.10 Skin Problems
Royal College of General Practitioners
14 Princes Gate | Hyde Park | London | SW7 1PU
Phone: 020 7581 3232 | Fax: 020 7225 3047
1
[CONTENTS]
[Acknowledgements]...................................................................................................................................3
Key messages ............................................................................................................................................3
[Introduction]................................................................................................................................................4
Rationale for this curriculum statement................................................................................................4
UK health priorities – UK drug treatment priorities ...........................................................................5
Treatment of drug misuse .......................................................................................................................6
Treatment of alcohol misuse...................................................................................................................7
[Learning Outcomes] ...................................................................................................................................8
Primary care management ......................................................................................................................8
The knowledge base.................................................................................................................................8
Person-centred care..................................................................................................................................9
Specific problem-solving skills...............................................................................................................9
A comprehensive approach ....................................................................................................................9
Community orientation .........................................................................................................................10
A holistic approach ................................................................................................................................10
Contextual aspects..................................................................................................................................10
Attitudinal aspects .................................................................................................................................10
Scientific aspects .....................................................................................................................................10
Psychomotor skills .................................................................................................................................10
[Further Reading] .......................................................................................................................................11
Examples of relevant texts and references..........................................................................................11
Web resources .........................................................................................................................................11
[Promoting Learning about Drug and Alcohol Problems]...................................................................13
Work-based learning – in primary care...............................................................................................13
Work-based learning – in secondary care...........................................................................................13
Non-work-based learning .....................................................................................................................13
RCGP Certificate in the Management of Drug Misuse......................................................................13
Learning with other healthcare professionals ....................................................................................14
[Appendix 1] ...............................................................................................................................................15
Guiding principles for the development of the Recovery Process ..................................................15
[Appendix 2] ...............................................................................................................................................17
Hidden harm – children of drug users................................................................................................17
[Appendix 3] ...............................................................................................................................................18
Asking about drugs................................................................................................................................18
Brief intervention for alcohol problems...............................................................................................18
Harm minimisation for alcohol.............................................................................................................18
[Appendix 4] ...............................................................................................................................................19
Models of Care framework ......................................................................................................................19
Implementing Models of Care.................................................................................................................19
[References] .................................................................................................................................................20
2
[ACKNOWLEDGEMENTS]
This curriculum statement has drawn on various national guidelines and policies, current
research evidence and the clinical experience of practising general practitioners.
The Royal College of General Practitioners would like to express its thanks to these individuals.
Author:
Contributors:
Editors:
Guardian:
Created & Updated:
Date of this update:
Dr Clare Gerada
Professor Steve Field, Dr Mike Deighan, Dr Amar Rughani, Dr
Stephen Kelly, Dr Martin Wilkinson, the RCGP Substance Misuse
Unit
Dr Mike Deighan & Professor Steve Field
Dr Clare Gerada
September 2005; December 2005
March 2006
Key messages
•
•
•
•
•
•
•
•
•
The use of illicit drugs, such as heroin or cocaine, is common.
All general practitioners have a responsibility for providing general medical care to drugusing adults.
General practitioners are ideally placed to identify drug misuse before it becomes
problematic and to be able to intervene effectively.
Drug use is amenable to treatment, using a combination of psychological, social and
medical interventions.
Substitution treatment, such as the use of methadone, is effective and properly
administered results in improvements in social, medical and psychological functioning,
and a reduction in criminal behaviour.
General practitioners must be familiar with ways of identifying excess alcohol
consumption.
Despite the prevalence of patients presenting to general practitioners with problems
relating to heavy alcohol intake, they often fail to make the association.1
General practitioners should be aware of the morbidity (physical, psychological and
social) caused by alcohol.
Health professionals can have a major impact in reducing alcohol consumption in their
patients by a simple technique called brief intervention.
3
[INTRODUCTION]
Rationale for this curriculum statement
Alcohol and psychoactive substances have been woven into every society since the beginnings of
the human race. The use of illicit drugs (heroin, cocaine, ecstasy, amphetamines and cocaine) in
the United Kingdom has risen year on year over the last few decades and national figures for
England (2001/2) report that the number of users (predominately heroin) in treatment with drug
services and general practitioners (GPs) is around 150,000.2 The breakdown of the main illicit
drugs used in Scotland (Table 1) demonstrates the spread of drugs misused.
Table 1: Main illicit drugs in Scotland: year ending 31 March 20023
GPs and primary healthcare teams play an important part in addressing the health and social
problems associated with drug and alcohol use, and GPs have been at the heart of many of the
recent developments in the treatment of substance misuse across the NHS. This has included the
provision of care to opiate users and the provision of harm reduction and brief intervention to
drug and alcohol users.
Over the last decade the RCGP has been providing leadership in the field of primary care
substance misuse and has been instrumental in changing the attitudes of many GPs such that the
management of these patients is now seen by many as part of normal general practice either as
part of routine care or as an enhanced service.
Perhaps the turning point in the involvement of GPs in the care of drug users was following
the publication of a joint statement in April 2000, from the RCGP and the General Practitioners
Committee of the British Medical Association. This statement reflected the change in attitude in
primary care’s involvement in the care of drug users and reaffirmed from the two leading UK
primary care organisations the responsibility of GPs to care for these patients. The statement
made was as follows:
’The RCGP and GPC believe that GPs should offer appropriate care to all patients on their list. Where
patients have problems with substance abuse, appropriate care will include aspects of primary care
normally provided by the practice health care team, shared care with other services and referral to other
4
appropriate services. Certain GPs may develop experience in their care of substance abuses, and the
number and location of these doctors should ideally, be sufficient to avoid substantial workload falling
onto only a few GPs.’
A survey of GPs in England and Wales in 2005 has found that half of all GPs who responded
had seen an opiate user in the preceding four weeks and half of these (25% of the total sample)
had prescribed opiate–substitute therapies. Extrapolated across the whole GP population
approximately 62,000 opiate misuses were being seen by GPs over a four-week period in 2001.4
These figures represent a substantial increase in the numbers of GPs involved in the care of drug
users compared with the results of a similar survey conducted a decade earlier.
The National Treatment Agency for Substance Misuse, the RCGP and the Royal College of
Psychiatrists have recently published5 a joint paper outlining the roles and responsibilities,
clinical governance arrangements and other key areas for doctors working with drug users at
different levels of expertise. The document builds on the work carried out by the RCGP in
defining criteria, standards and evidence required for practitioners working with drug users and
a training programme established to deliver these criteria. These publications provide essential
guidance for trainees and trainers in both hospital and general practice working at generalist,
intermediate (practitioner with special interest) and specialist levels of service provision.
Nearly one-fifth of patients treated in general medical practices report drinking alcohol at
levels considered ’risky’ or ’hazardous’ and may be at risk of developing alcohol-related
problems as a result. Excess alcohol use plays a significant part in the epidemiology of health and
social problems, and is responsible for significant morbidity. The true impact on the public’s
health of excess alcohol consumption is difficult to evaluate but is likely to be considerable as
Table 2 below illustrates.6
Table 2: Burden of excess alcohol consumption to health and social care
• Expenditure of £95m on specialist alcohol treatment
• Over 30,000 hospital admissions for alcohol dependence syndrome
• Up to 22,000 premature deaths per annum
• At peak times, up to 70% of all admissions to accident and emergency
departments
• Up to 1000 suicides
• 1.2m violent incidents (around half of all violent crimes);
• 360,000 incidents of domestic violence (around a third) that are linked to
alcohol misuse
• Increased anti-social behaviour and fear of crime – 61% of the population
perceive alcohol-related violence as worsening
• Up to 17m working days lost through alcohol-related absence
• Between 780,000 and 1.3m children affected by parental alcohol problems
• Increased divorce – marriages where there are alcohol problems are twice as
likely to end in divorce
Source:
Alcohol
Harm
Reduction
Strategy
for
England,
www.strategy.gov.uk/work_areas/alcohol_misuse/index.asp
2004,
UK health priorities – UK drug treatment priorities
The National Treatment Agency for Substance Misuse (NTA) Models of Care of the Treatment of
Adult Drug Misuses: framework for developing local systems of effective drug misuse treatment in
England (2002)7 sets out a programme of action and reform to address the needs of drug users
and ensure that the quality of services is improved for them. The document sets out the national
standards and service models together with local action and national underpinning programmes
for implementation, a series of national milestones and performance measures. The range of
difficulties experienced by drug misusers is conceptualised as domains, commonly grouped as
5
four domains that can then be used to assess whether drug misusers are improving or achieving
better outcomes in these areas. The four key domains addressed in Models of Care are as follows:
1. Drug and alcohol use:
• Drug use, including type of drugs, quantity and frequency of use, pattern of use, route of
administration, source of drug
• Alcohol use, including quantity/frequency of use, pattern of use, whether above ‘safe’
level, alcohol dependence symptoms.
2. Physical and psychological health:
• Psychological problems, including self-harm, history of abuse/trauma, depression,
severe psychiatric co-morbidity, contact with mental health services
• Physical problems, including complications of drug/alcohol use, pregnancy, blood-borne
infections/risk behaviours, liver disease, abscesses, overdose, enduring or severe physical
disabilities.
3. Social functioning:
• Social problems (including child care issues, partners, domestic violence, family, housing,
employment, benefits and financial problems).
4. Criminal involvement:
• Legal problems (including arrest, fines, outstanding charges/warrants, probation,
imprisonment, violent offences, criminal activity).
Models of Care also provides a conceptual framework to aid rational and evidence-based
commissioning of drug treatment services in England (see Appendix 3).
Hierarchy of goals of drug treatment
For some years now a range, or hierarchy, of goals of drug treatment has been identified in the
UK; these were determined by the Task Force to Review Services for Drug Misusers, in 1996.8
These relate to the above domains and are:
• Reduction of health, social and other problems directly related to drug misuse
• Reduction of harmful or risky behaviours associated with the misuse of drugs (for
example sharing injecting equipment)
• Reduction of health, social or other problems not directly attributable to drug misuse
• Attainment of controlled, non-dependent or non-problematic drug use
• Abstinence from main problem drugs
• Abstinence from all drugs.
The hierarchy of drug treatment goals endorses the principle of harm reduction, which refers to
the reduction of the various forms of drug-related harm (including social, medical, legal and
financial) until the drug user is ready to come off drugs.
Treatment of drug misuse
Treatment of drug misuse needs to address the social, physical and psychological components of care. The
role of pharmacological treatments is as follows:
• Management of withdrawal symptoms
• Reduction of physical, social and psychological harms to the individual and the public
associated with illicit drug use by prescribing a substitute drug or drugs (for example
methadone maintenance treatment in which aims may include cessation of injecting;
reduction or cessation of illicit heroin use; and reduction or cessation of other high-risk
behaviours)
• Relapse prevention and maintenance of abstinence
• Prevention of complications of substance use (for example, hepatitis B immunisation, the
use of thiamine to prevent Wernicke’s encephalopathy and Korsakoff’s syndrome).
6
Treatment of alcohol misuse
Having identified harmful drinkers, simple, brief interventions delivered by general medical
practitioners and other primary healthcare staff are effective in reducing drinking levels to lowrisk levels among hazardous and harmful drinkers.9 The intervention can be as basic as fivestructured advice and the effect can still be shown in follow ups for up to two years.
There are a number of large scale systematic reviews and meta-analyses showing brief
intervention is effective in reducing alcohol use amongst hazardous and harmful drinkers. The
results of these are summarised in the Health Development Agency’s Prevention and Reduction of
Alcohol
Misuse:
evidence
briefing,
March
2005,
www.publichealth.nice.org.uk/download.aspx?o=503439.
7
[LEARNING OUTCOMES]
The following learning objectives relate specifically to drug and alcohol problems. This RCGP
curriculum statement should be used in conjunction with the other curriculum statements,
especially the core RCGP curriculum statement 1, Being a General Practitioner, and Care of People
with Mental Health Problems.
Primary care management
The work of the GP increasingly involves the care of drug users in partnership with the wider
primary healthcare team, both within their own practice, in the local community, and also with
specialists in secondary care and in partnership with the voluntary and criminal justice sector.
This role involves understanding the special needs of a disadvantaged and challenging group,
and requires problem-solving skills at the teamworking and management level as well as at the
clinical one.
Thus primary care education must promote learning that integrates different disciplines
within the complex team of the NHS. Specialty registrars (GP) must learn the importance of
supporting patients’ decisions about the management of their health problems and
communicating how that care will be delivered by the NHS team as a whole.
The knowledge base
Symptoms and signs:
• Of opiate misuse – needle track marks, pinpoint pupils, runny nose, drowsiness
• Of stimulant use – agitation, skin ulceration
• Suggestive of cannabis use – red eyes, irritability, anxiety, panic disorder
• Manifestation of alcohol problems:
o physical: accidents, victim of violence, obesity, dyspepsia, erectile dysfunction,
fits, foetal alcohol syndrome, liver damage, anaemia, neurological and central
nervous system problems
o psychological: anxiety, depression, attempted suicide
o social: loss of employment, disorderly conduct, domestic violence, drink–driving,
relationship problems or breakdown.
Common and/or important conditions:
• The common complications of drug-using or misusing habit:
o those related to the drug used (e.g. heroin, cocaine, alcohol, cannabis)
o those related to the route of use (such as injecting, inhalation)
o those related to the lifestyle related to a drug-using habit (poor nutrition, poor
dentition, social problems).
• Have an understanding of the aetiology, presenting symptoms, treatment and prevention
of HIV infection, hepatitis A, hepatitis B, hepatitis C
• The health and social burden of excess alcohol consumption.
Investigations:
• Have an understanding of the nature and role of urine, and other tests in the
management of drug treatment
• The use of screening tools for alcohol such as Cut down Annoyed Guilty Eye-opener
8
(CAGE) and Alcohol Use Disorders Identification Test (AUDIT).
Treatment:
• The National Clinical Guidelines for the care and management of a drug-using patient
• The principles and practice of appropriate safe prescribing for patients who use drugs
• The principles and practice of dose induction and safe prescribing for the drug-using
patient
• The range of treatment interventions available including pharmacological interventions
• The impact that health professionals can make by providing brief intervention for excess
alcohol use.
Emergency care:
• Have an understanding of the aetiology and prevention of drug-related deaths
• Alcohol-related emergencies such as fits, delirium and psychosis.
Prevention:
• Have an understanding of the term harm reduction, the strategies that can be employed
in harm reduction and the advantages and disadvantages of undertaking a harm
reduction approach to treatment.
Person-centred care
• Adopt a person-centred approach, whilst acknowledging the conflicts between a
perceived self-inflicted problem and a right to evidence-based treatment.
• Enable drug and alcohol abusers to recognise that a problem exists, engage in delineating their
difficulties and deciding on appropriate interventions.
• Demonstrate an awareness of the special challenges of establishing and maintaining rapport
with patients with drug and alcohol misuse problems, especially given the chaotic and
challenging ways in which they may use the service.
Specific problem-solving skills
•
•
•
•
•
•
Describe the ways in which patients who use illicit drugs present to services.
Describe how to assess the prevalence of drug and alcohol issue problems and needs among
their practice’s population.
Demonstrate understanding of the difference between dependent and problematic drug and
experimental drug and alcohol use.
Identify physical, social and psychological problems associated with drug use.
Describe how to assess risk and suicidal ideation.
Describe what action to take when there is an immediate risk of danger to drug users.
A comprehensive approach
• Describe the factors that lead to the neglect of health and health care in this group and take
steps to counter these.
• Describe how to manage the associated physical health problems of people with drug misuse
problems.
• Demonstrate understanding of the relationship between drug misuse and offending
behaviour.
9
• Demonstrate understanding of the relationship between drug misuse and mental health
problems.
• Demonstrate understanding of the concept of recovery and the principles of promoting
recovery (see Appendix 1).
Community orientation
•
•
Demonstrate awareness of the extent and implications of stigma and social exclusion.
Demonstrate understanding of how to challenge inequality through:
o working in partnership with other agencies to secure appropriate health and social
interventions for individuals
o contributing to the health improvement programme that reflects the perspective of
the local population.
A holistic approach
• Demonstrate understanding of the impact that social circumstances can have on drug misuse
and that recovery is contingent on the effective management of those social circumstances.
• Demonstrate an awareness of the vulnerability of children whose parents are drug users and
understand the role that the child may adopt as carer in such circumstances.10
• Demonstrate an awareness that the causes of drug misuse are multifactorial.
• Demonstrate cultural sensitivity.
Contextual aspects
• Demonstrate knowledge of the Misuse of Drugs Act (1971) and how it impacts on health
professionals in their treatment of drug users.
• Demonstrate an awareness of the political changes that impact on the management of
drug users.
Attitudinal aspects
• Demonstrate an awareness that their own attitudes and feelings are important determinants of
how they manage:
o
people who self-harm
o
people who misuse drugs or alcohol
o
people who know more about their illnesses than their doctors do
o
people who engender strong emotions in us for many reasons.
• Demonstrate an understanding that their personal values and attitudes should not
inappropriately influence their professional decisions or the equality of patients’ access to
care.
Scientific aspects
•
Demonstrate an understanding that a critical and research-based approach to practice is
particularly important in drug misuse treatment, where evidence on effective treatment is
often of poor quality.
Psychomotor skills
Demonstrate how to conduct a:
• Mental state assessment
• Suicide risk assessment
• Drug use risk assessment.
10
[FURTHER READING]
Examples of relevant texts and references
• British Medical Association and Royal Pharmaceutical Society of Great Britain. The British
National Formulary 50 London: BMJ Books, 2005
• Bury M. Health and Illness in a Changing Society London: Routledge, 1997
• Department of Health, Scottish Office Home and Health Department, Welsh Office. Drug
Misuse and Dependence, Guidelines on Clinical Management London: HMSO, 1991
• Department of Health, Scottish Office Department of Health, Welsh Office, Department of
Health and Social Services, Northern Ireland Drug Misuse and Dependence. Guidelines on
clinical management London: The Stationery Office, 1999
• Gerada C (ed.). RCGP Guide to the Management of Substance Misuse in Primary Care London:
RCGP, 2005
• Jones R, Britten N, Culpepper L, et al. (eds). The Oxford Textbook of Primary Medical Care Oxford:
Oxford University Press, 2004
• Schellevis FG, van der Velden J, van de Lisdonk EH, van Eijk JTM, van Weel C. Co morbidity
of chronic diseases in general practice J Clin Epidemiol 1993; 46: 463–73
• Wanless D. Securing Good Health for the Whole Population: final report London: HSMO, 2004
• Wright N. Homelessness: a primary care response London: RCGP, 2002
Web resources
Driving under the influence of drugs: an internet resource
This site was developed by the British Medical Association in response to a request made at their
ARM (Annual Representatives Meeting) in 2001 to consider ways of supporting the police in
their fight against drug driving by raising awareness and educating the public on the potential
dangers. This site provides an outline of the current situation with regard to drug driving and
what actions the BMA would like the government to take. Specific issues covered include: tests
for drug driving; summary of research; and projects in the UK and international research.
www.bma.org.uk/ap.nsf/Content/__hub+science+drug+driving
Drugs.gov.uk
This website is for anyone who works in the drugs field or is carrying out research in this area. It
has up-to-date information including the latest on government policy, research, legislation and
the Drug Strategy Aims, news and press cuttings, drugs events and conferences, good practice
and guidance, help with planning and running local campaigns. There is also a downloadable
photo library, a case studies section and a ‘Talking Shop’ area with a user forum.
www.drugs.gov.uk/
Health Education Board for Scotland
The Health Education Board for Scotland (HEBS) was established on 1 April 1991, replacing the
Scottish Health Education Group as the national agency for health education in Scotland. HEBS is
a Special Health Board within NHSScotland. Its website provides valuable information and links
for GPs and the public in Scotland.
www.hebs.scot.nhs.uk/
National Treatment Agency for Substance Misuse
The National Treatment Agency for Substance Misuse (NTA) aims to increase the availability,
capacity and effectiveness of treatment for drug misuse in England. The NTA works in
11
partnership with central government, drug action teams, treatment commissioners, providers
and service users, carers and families, researchers, academics, trainers and criminal justice
agencies to improve drug treatment.
www.nta.nhs.uk/
Scottish Drugs Forum
The Scottish Drugs Forum (SDF) is a national non-government drugs policy and information
agency working in partnership with others to coordinate effective responses to drug use in
Scotland. SDF aims to support and represent, at both local and national levels, a wide range of
interests, promoting collaborative, evidence-based responses to drug use.
www.sdf.org.uk
SIGN Guideline: The Management of Harmful Drinking and Alcohol Dependence in Primary
Care
The Scottish Intercollegiate Guidelines Network (SIGN) was formed in 1993. Its objective is to
improve the quality of health care for patients in Scotland by reducing variation in practice and
outcome, through the development and dissemination of national clinical guidelines containing
recommendations for effective practice based on current evidence. SIGN has a programme of 113
evidence-based clinical guidelines – published, in development or under review – covering a
wide range of topics.
www.sign.ac.uk/guidelines/fulltext/74/index.html
Substance Misuse Management in General Practice
Substance Misuse Management in General Practice (SMMGP) is a developing network to support
GPs and other members of the primary healthcare team who work with substance misuse in the
UK. The project team produces the Substance Misuse Management in General Practice
newsletter, Network, and organises the annual conference, ‘Managing Drug Users in General
Practice’. The first conference was held in 1996. It was organised through the Royal College of
General Practitioners (RCGP) HIV Working Party (which since 2001 has been renamed the RCGP
Sex, Drugs and HIV Task Group).
Management and partnership arrangements have now been made with the Royal College of
General Practitioners, Trafford Substance Misuse Services, and the National Treatment Agency.
These arrangements ensure that SMMGP remains rooted in primary care while being close to the
policy centre. The project was commissioned by the RCGP to develop and run the RCGP
Certificate in the Management of Drug Misuse - Part 1, and has enabled over 300 GPs to obtain the
full Part 1 certificate. More details on the Part 1 can be found in the RCGP section of its website.
This is the best website for GPs on drug misuse.
www.smmgp.org.uk
www.smmgp.org.uk/html/rcgp.php
Turning Point
A social care organisation providing a wide range of substance misuse services across England
and Wales. These include community drug services, services for clients with complex and
multiple needs, specialist alcohol services, crack services and young people’s services. Its site
contains more detailed information on all of their service locations.
www.turning-point.co.uk/
12
[PROMOTING LEARNING ABOUT DRUG AND
ALCOHOL PROBLEMS]
Work-based learning – in primary care
The period of time spent in general practice is ideal for gaining a better understanding of the care
of drug users. The specialty registrar (GP) will have the opportunity to care for drug users who
have physical and psychological and social problems, and who may be in receipt of substitute
medication. Many will experience contact with secondary care services and will be cared for by
different members of a wider multiprofessional team.
The specialty registrar should be encouraged to look after some of the practice’s drug-using
patients throughout the placement and follow them along their journey to gain a better
understanding of their problems and of the social and medical care that they receive.
The specialty registrar should take the opportunity to visit local voluntary organisations, e.g.
Turning Point, to gain a better understanding of their important role in supporting people with
substance and alcohol misuse in the community.
Work-based learning – in secondary care
Placements in addiction specialist or community drug and alcohol services are ideal for doctors
training to be GPs. Care must be taken to ensure that the learning is focused on the needs of the
specialist registrar who is placed in the department as part of a GP training programme. Such
placement has been in operation in South London for the last eight years, where the SHO
undertakes his or her psychiatric attachment placed in a community drug and alcohol services
(CLAS) team. 11
Non-work-based learning
Drug-using patients often have many complex psychological, social and physical problems,
which provide rich subjects for tutorials and case-based learning.
As indicated above, the SMMGP is a developing network to support GPs and other members
of the primary healthcare team who work with substance misuse in the UK. The project team
produces the SMMGP newsletter, Network, and organises the annual conference, ‘Managing Drug
Users in General Practice’.
RCGP Certificate in the Management of Drug Misuse
Part 1 to the RCGP Certificate in the Management of Drug Misuse was launched at the 9th
National Conference ‘Management of Drug Users in Primary Care’ in Cardiff. Part 1 is ideal for
GPs working at a generalist level, as part of a shared-care scheme, especially those intending to
provide treatment to drug users as part of a locally or nationally enhanced service (L/NES).
The course is mapped to the Drug and Alcohol National Occupational Standards (DANOS)
and is endorsed by the National Treatment Agency for Substance Misuse. At the moment Part 1
is only available to GPs, but it is being developed for nurses, user advocates and others. The
course is to be delivered in two stages: e-modules and face-to-face training. The e-learning
modules began in June 2004 and can be accessed at www.doctors.net.uk in the Education section
by anyone who has a GMC number. The training days are run locally and nationally.
Part 2 is a continuation of the existing certificate and is aimed at practitioners wishing to
become GPs with a Special Clinical Interest or a practitioner with Special Interest. There is an
expectation that candidates will have completed the Part 1 certificate or equivalent training
(recognised by the RCGP or sister organisations), or can demonstrate that they already have the
13
generalist competencies. Part 2 is open to GPs, nurses, pharmacists, user advocates, expert
patients, psychiatrists, shared-care workers, and others with appropriate background.
Learning with other healthcare professionals
The specialty registrar is encouraged to learn alongside other professional colleagues who will be
involved in the care of drug users. This will enrich the learning experience and all parties will be
able to draw on the expertise of others. (See above for details about Part 2 of the RCGP Certificate
in the Management of Drug Misuse.)
14
[APPENDIX 1]
Guiding principles for the development of the recovery process 12
Principle I
The user of services decides if and when to begin the recovery process and directs it; therefore,
service user direction is essential throughout the process.
Principle II
The mental health system must be aware of its tendency to promote service user dependency.
Principle III
Users of service are able to recover more quickly when their:
• Hope is encouraged, enhanced and/or maintained
• Life roles with respect to work and meaningful activities are defined
• Spirituality is considered
• Culture is understood
• Educational needs as well as those of families/significant others are identified
• Socialisation needs are identified
• They are supported to achieve their goals.
Principle IV
Individual differences are considered and valued across the life span.
Principle V
Recovery from mental illness is most effective when a holistic approach is considered; this
includes psychological, emotional, spiritual, physical and social needs.
Principle VI
In order to reflect current ‘best practices’ there is a need for an integrated approach to treatment
and care that includes medical/biological, psychological, social and values-based approaches. A
recovery approach embraces all of these.
Principle VII
Clinicians’ and practitioners’ initial emphasis on ‘hope’ and the ability to develop trusting
relationships influence the recovery of users of services.
Principle VIII
Clinicians and practitioners should operate from a strengths/assets model.
Principle IX
Users of service with the support of clinicians, practitioners and other supporters should develop
a recovery management or wellness recovery action plan. This plan focuses on wellness, the
treatments and supports that will facilitate recovery, and the resources that will support the
recovery process.
15
Principle X
Involvement of a person’s family, partner and friends may enhance the recovery process. The
user of service should define whom they wish to involve.
Principle XI
Mental health services are most effective when delivery is within the context of the service user’s
locality and cultural context.
Principle XII
Community involvement as defined by the user of service is central to the recovery process.
16
[APPENDIX 2]
Hidden harm – children of drug users 10
Parental drug use in isolation is not automatically correlated with poor parenting and many drug
users do manage to provide good parental care, especially if they are in appropriate treatment.
On the other hand, chaotic parental drug misuse may compromise the health and development
of a child at any stage. Effects vary according to the child’s age and stage of development, and
problems may be cumulative and are often multiple. In assessing drug-using parents, it is
important to assess the quality of parenting overall rather than focusing exclusively on drug use.
Other professionals such as social workers, teachers and health visitors should be involved in this
process.
Examples of the range of problems that may be faced by children whose parents have unstable
drug use include:
• Increased risks of accidents
• Physical and emotional abuse (usually neglect)
• Poverty
• Inadequate parental supervision
• Inappropriate parenting practices
• Intermittent or permanent separation
• Inadequate accommodation, frequent changes of residence
• Risks associated with toxic substances and inappropriate individuals in the home.
The ratio of male to female drug users approaching treatment services is around 3:1, though
community-based surveys involving out-of-contact users makes the ratio much closer to 2:1,
indicating that while there are probably greater numbers of male drug users, female drug users
may be more reluctant to approach treatment services, due to the increased stigma attached to
female drug use and fear regarding children and the involvement of social services.
Prevalence of children at risk
• We estimate there are between 200,000 and 300,000 children in England and Wales where one
or both parents have serious drug problems. This represents about 2–3% of children under 16.
Only 46% had their children living with them; 54% had children living elsewhere (usually
with other family members or friends) including 9% whose children were in care.
• We estimate there are between 41,000 and 59,000 children in Scotland with a problem drugusing parent. This represents about 4–6% of all children under 16. There are estimated 10,000–
19,000 children in Scotland living with a problem drug-using parent.
17
[APPENDIX 3]
Asking about drugs
•
•
•
Ideally doctors should ask all patients about their drug use (prescribed and nonprescribed), e.g. ‘Do you smoke cigarettes? What about alcohol? And do you use any
other drugs?’
Given the opportunity many patients will volunteer problem drug use.
The doctor should then ask:
o What do you use?
o How much per day? Per average week?
o What route? (oral, injecting, smoking)
o Longest period of abstinence?
o Treatment history.
Brief intervention for alcohol problems
Brief intervention involves the following:
F
feedback
R
responsibility
A
advice
explicit advice on changing drinking behaviour
M
menu
offering alternative goals and strategies
E
empathy
S
self-efficacy
assessment and evaluation of the problem
emphasising that drinking is by choice
the role of the counsellor is important
instilling optimism that the chosen goals can be achieved
Harm minimisation for alcohol
Harm minimisation interventions include advising where drinking should be avoided. These
include:
• Before or during driving
• Before swimming
• Generally, before or during active physical sport
• Before working or in the workplace when appropriate functioning would be adversely
affected by alcohol
• When taking medication, where alcohol is contraindicated.
18
[APPENDIX 4]
Models of Care framework
The National Treatment Agency for Substance Misuse (NTA) Models of Care of the Treatment of
Adult Drug Misusers: framework for developing local systems of effective drug misuse treatment in
England (2002)7 sets out a programme of action and reform to address the needs of drug users
and ensure that the quality of services improved for them.
Models of Care Part 1 and Part 2 provide a national framework for drug treatment services in
England that should be used as a guide for all drug action teams (DATs) as they proceed with
their plans to expand and improve the drug treatment services in their area.
The overriding concept behind Models of Care is that DATs should be seeking to develop an
integrated drug treatment system in their area, not just a series of separate services. In the last few
years, DAT members have received increasing funding to expand the capacity of the various
modalities of treatment, but it is also felt that efforts must be made to combine these modalities
into a seamless system of ‘care pathways’ for patients. The Models of Care approach describes how
these processes of care would work, based on the menu of treatment services that have already
been incorporated into DAT treatment plans, but now expressed in terms of four treatment
’tiers’.
Tier 1
non-substance misuse specific services requiring interface with drug and alcohol
treatment
Tier 2
open-access drug and alcohol treatment services
Tier 3
structured community-based drug treatment services
Tier 4
residential services for drug and alcohol misusers
The Royal College of General Practitioners has clarified the tiers at which practitioners with
varying levels of skills may work.
GP providing core services
Tier 1
GP providing essential services
Tier 1
GP providing locally enhanced services
Tier 1
GP providing nationally enhanced services
Tier 1–2
GP with special clinical interest providing enhanced services
Tier 1–2
GP with special clinical interest providing services to PCO
Tier 2–3
Specialist generalist providing specialist services under GMS or specialist
PMS arrangements
Tier 3–4
Implementing Models of Care
Implementing Models of Care requires the development of a number of locally agreed screening
and assessment instruments. It also requires the establishment of care coordination for clients
with complex needs.
A toolkit has been developed that contains top tips and a number of instruments developed
by the various Enhancing Treatment Outcome (ETO) pilots that have been running throughout
the country. These tools include assessment forms, care plans and a number of other items that
may be useful in addressing these issues. See www.nta.nhs.uk/ for more information.
19
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Possibly the best summary of the effectiveness is found in: Scottish Intercollegiate Guidelines
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[accessed January 2007]
20